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Updated on: March 16, 2016

Pressure and Progress Line the Road to ICD-10 Readiness for Payers

Original story posted on: January 20, 2014

Just a year ago, the idea of actually being ready for ICD-10 implementation by October 1, 2014, seemed a distant dream, full of confusion and panic.

Since then, a lot of people have done a lot of work to get the ball rolling in the right direction, and the guests on the January 13 edition of the “Talk-Ten-Tuesday” broadcast, produced by ICD10monitor, shared the progress they’re making in two important areas: payer readiness and physician education.


All three payers on the Tuesday broadcast believe that the infrastructure changes they need to implement ICD-10 are in “pretty good shape,” as Dennis Winkler, director of technical program management at Blue Cross Blue Shield of Michigan, put it.

Sidney Hebert, Humana’s director of integrated provider process solutions and ICD-10 program manager, also says his company is “well down the path,” and Ross Lippincott, vice president of UnitedHealthcare’s Regulatory Implementation Office, reported that the company’s “system changes are complete.”

Another guest, James Fee, M.D., associate director for Huff DRG Review Services, also is working on system changes but of a human kind. Specifically, he’s part of the industry team working to get physicians ready for the switch, and he sees the biggest challenge as physician buy-in and understanding.

To meet this challenge, Dr. Fee and his staff focus on “teaching physicians exactly what they need to know,” according to their specialties, instead of general ICD-10 concepts. “We address their specific documentation issues versus their cohorts’ issues,” said Dr. Fee, who is also an AHIMA-approved ICD-10-CM/PSC trainer.

Initially, staff from Huff DRG Review Services review a physician’s actual charts and accumulate the needed documentation data. The education commences when they share their findings, review the cases, and explain the documentation that is missing for specific procedures.

When the time comes, clinical documentation improvement (CDI) specialists will play a significant role in the physician-education process, Dr. Fee said. The biggest challenge they face is prioritizing queries.

“It will be the CDI specialist’s role to talk with physicians and guide them to provide the appropriate documentation and reach the ultimate goal of increased specificity,” he says.

Payers Focus on Provider Readiness

Blue Cross Blue Shield managers and staff are concentrating on provider readiness, which involves two components: communication and testing.

Winkler explained that the company is using the standard channels like provider newsletters, website postings, and I-10 presentations. They now invite providers to participate in the company’s monthly conference calls, which they call Michigan Mondays. On-site presentations and monthly educational sessions also have been added to the mix.

Beyond provider education, Blue Cross Blue Shield of Michigan is now conducting full compliance testing with third-party administrators (TPAs), billers, and clearinghouses. Winkler reports, “We are live with the capability to test with all of our professional providers. We just finished our pilot with facilities and will go live soon. Selected end-to-end testing is also underway.”

UnitedHealthcare also is concentrating on provider readiness in addition to testing. Lippincott says that the company is now wrapping up its internal testing, and external testing has been underway for some time.

“Externally we’ve conducting DRG shift testing analysis since Q2 2013,” says Lippincott. “We’ve learned a lot with this and have worked through test claims with several facilities.”

In addition, he says, “We are now exchanging info with our business partners, and we’ll process test claims up until September and exchange results.”

For UnitedHealthcare, as with other payers, operational readiness is another issue that must be addressed. As Lippincott explained, “We’ve completed some initial assessments on the impact that I-10 will have on operations. We expect that we will receive more phone calls and will need additional claim adjustors.” To ensure a smooth transition, they’ve already starting hiring staff to fulfill these and other roles because some positions require several months of training.

In terms of readiness, Humana shares the boat with the above payers, stated Humana’s Hebert.

“We’ve completed our remediations, a full round of infrastructure testing, and business validation,” he says. “We’re taking a content and risk-based approach to validate our business. This means we have rich test suites built around specific coding conditions that are going to prevent problems, such as DRG shifting, which will be a big one.”

In addition to traditional forms of outreach to providers, Humana is focusing on provider-practice testing and reviewing DRG shifting with facilities and problematic codes. Hebert explains this as a “rigorous process” of evaluating a provider’s history and identifying the potential risks.

For example, with facilities, “We build testing scenarios for coding capability, documentation, and end-to-end production.” Humana also is building a simulation of submissions from individual practices.

“We don’t know how broad that model will be since we have a national footprint,” says Hebert, “but we’re trying to come up with high-volume way to do end-to-end testing for practices.”

All in all, all payers on the broadcast believe that will be ready when the implementation date comes around because, as Hebert said, “we’ve done enough legwork to ensure providers and submitters are ready.”


Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Janis Oppelt

Janis keeps the wheel of words rolling for Panacea®'s publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for RACMonitor.com and ICD10Monitor.com; coordinating the compliance question of the week; and contributing to the annual book-update process. She has 20 years of experience in topics related to Medicare regulations and compliance.

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